Vermont Public has traveled the state in recent months to find out what issues Vermonters care about most this election season, and for many of you, health care is at the top of the list.
We’ve spoken with residents who say they can no longer afford health insurance premiums, co-pays and deductibles. And many of you have trouble accessing even basic medical services, like primary care.
That made us wonder — what could Vermont’s next Legislature and governor do next year to make health care more affordable and accessible? So, we talked to experts with deep knowledge of the health care system in Vermont to find out what elected officials can do to mend a broken system.
More from Vermont Public: Start here if you care about health care in Vermont’s 2024 election
Vermont Public’s Jenn Jarecki spoke with reporter Peter Hirschfeld to learn more about what they said. This interview was produced for the ear. We highly recommend listening to the audio. We’ve also provided a transcript, which has been edited for length and clarity.
Jenn Jarecki: Were there any themes among the folks you talked to, in terms of concrete actions lawmakers and the governor can take next year to begin to address health care challenges in this state?
Peter Hirschfeld: Yes, and perhaps disappointingly, one common theme is that elected officials at the state level are somewhat limited in their ability to undertake the sorts of reforms that are going to generate transformational change, at least in the short term.
They can’t touch Medicare, which is administered by the feds. They can’t touch self-insured businesses, which represent about a third of Vermonters who have health insurance. And they’ve given authority over things like hospital budgets and insurance premiums to the Green Mountain Care Board, which is its own independent regulatory body.
Jill Olson used to oversee legislative policy for hospitals in Vermont. She now heads up the Visiting Nurses Association. And she says these realities constrain what lawmakers and the governor can actually do.
Jill Olson: There’s a lot that we don’t have control over as a state. We are really ambitious about health care reform in Vermont, but the federal government and federal pressures have a huge impact.
Jenn Jarecki: So what powers do elected officials have over health care? And how can they leverage those to make a real difference for Vermonters?
Peter Hirschfeld: One big area is Medicaid. This is the program that provides insurance to low-income Vermonters, and it’s one of the largest payers in Vermont’s health care system.
Michael Costa, who used to help run Vermont’s Medicaid program for the Scott administration, and who now serves as CEO of Gifford Medical Center in Randolph, says Medicaid is one area lawmakers can make a real difference.
Providers say that Medicaid reimbursement rates — which are set by the state — generally fall well short of what it costs to provide care. Costa says this has the effect of driving up costs for people who have to buy private insurance policies. And he says it’s also a huge factor in the financial challenges that most Vermont hospitals are experiencing right now.
Michael Costa: And so fully funding Medicaid first would really set the tone that we’re serious about having a sustainable health care system.
Jill Olson, at the Visiting Nurses Association, says she thinks it’s especially important for lawmakers to boost Medicaid reimbursement rates for the sorts of services — and we're talking about things like long-term home care for example — that can often provide a better and cheaper alternative to hospital care.
Jenn Jarecki: OK Pete, but is there universal support for increasing Medicaid reimbursement to health care providers?
Peter Hirschfeld: The short answer is no. The elephant in the health care waiting room, so to speak, is a recent report commissioned by the Green Mountain Care Board that calls for the closure or reconfiguration of many small hospitals in Vermont.
Health care providers, including hospitals, like the idea of increasing Medicaid payments because it provides a path to solvency that could help them avoid closure.
But Mike Fisher, Vermont’s chief health care advocate, says Vermont can’t spend its way out of this problem. He says a health care system that has 14 hospitals for a population of 660,000 people creates inefficiencies and redundancies that can drive up the cost of care. He says structural reforms, like the ones the Green Mountain Care Board report calls for, may be the only way to get a handle on these cost pressures.
And he says one thing lawmakers can do next year to improve health care in this state is to give the Green Mountain Care Board the moral support and political capital that it's going to need in order to move forward with structural — and often unpopular — changes to hospitals.
Mike Fisher: The way we’re moving right now, I think, to all who are looking carefully at it, feels like we’re running off a cliff. And to try and pull back on the reins, or to try and turn before the precipice, is going to take all hands on deck. It’s going to really take the Legislature weighing in, I believe.
Jenn Jarecki: Moral support and political capital. What exactly does that look like Pete?
Peter Hirschfeld: So, there are communities in which lots of folks are really upset by the proposals that are called for in this Green Mountain Care Board report. As you can imagine, when somebody talks about closing or structurally overhauling a local institution like that, people get concerned.
One thing folks are concerned about who support these kinds of structural changes to hospitals is that constituents are going to ask their representatives in the House and Senate to make sure that these changes don't happen. And that lawmakers will, in turn, pass legislation that makes it more difficult for the Green Mountain Care Board or the Agency of Human Services to move forward with the sorts of changes called for in that report.
What Mike Fisher is saying is that it's important that lawmakers stand firm and allow the Green Mountain Care Board and the administration to retain the kind of authority they need to move forward with changes that may be really unpopular in some communities.
Jenn Jarecki: One more question for you, Pete. Vermonters who participated in our Citizens Agenda had a lot to say about primary care, or lack thereof. Any big ideas to improve access on that front?
Peter Hirschfeld: Jessa Barnard is the head of the Vermont Medical Society. She says the state has enjoyed some real success with what are known as patient-centered medical homes. This is a model where primary care doctors partner with other providers to create a more holistic approach to health. And Barnard says it’s working.
Jessa Barnard: In the latest review, patients who went to a patient-centered medical home, which is the majority of primary care practices in Vermont, saw their primary provider more but spent less on medical care and pharmacy services.
Peter Hirschfeld: The problem, Barnard says, is that commercial insurance companies, like Blue Cross Blue Shield for example, are paying the same amount per patient per month for these services as they were nearly 10 years ago. And she says lawmakers could strengthen and improve this care model by requiring insurers to up their contributions.
Have questions, comments or tips? Send us a message.
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